Every finding on record at Rc Home Healthcare Inc

The following reflects the findings of the California Department of Public Health during a recertification survey conducted May 19, 2025, through May 22, 2025. Census: 35 Unduplicated Admissions: 33 Home Visits with record reviews: 3 Record Reviews without home visits: 4 Sample Size: 7 The Condition of Participation for the Emergency Preparedness Program was met.

The following reflects the findings of the California Department of Public Health during a recertification survey conducted May 19, 2025, through May 22, 2025. Census: 35 Unduplicated Admissions: 33 Home Visits with record reviews: 3 Record Reviews without home visits: 4 Sample Size: 7 Four deficiencies were issued during a recertification survey.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure a review of all the medications the patients were taking was conducted for two of seven sampled patients (Patients 1 and 2) when: 1. For Patient 1: the Medication Profile (MP-a current list of all medications prescribed for a specific patient), indicated tetracyte (an antibiotic which kills bacteria) was to be applied as a spray when the contracted wound care company's information sheet indicated the tetracyte was to be applied as drops to Patient 1's wound. This failure had the potential to cause a less precise measurement of medication when a small, specific volume was required. 2. For Patient 2: the MP indicated the wrong dose for two medications (tamsulosin-a medication that makes urination easier and ibuprofen-a pain medication) and one medication (atorvastatin- a medication to lower cholesterol and triglyceride levels in the blood) was not indicated on the MP. This failure had the potential to cause ineffective drug therapy, significant side effects and noncompliance with drug therapy for Patient 2. Findings: 1. A review of Patient 1’s care plan (contains information about a patient's diagnosis, the goals of treatment, and specific nursing orders), undated, indicated, a start of care date of April 1, 2022, with a recertification period of May 15, 2025, to July 13, 2025. Patient 1 had diagnoses that included stage III, pressure sore to the left hip (an open wound with full-thickness skin loss due to prolonged pressure). During a home visit observation on May 20, 2025, from 11:15 AM to 12:26 PM, with a Licensed Vocational Nurse (LVN 1), LVN 1 was observed performing Patient 1’s wound care. LVN 1 administered a few drops from a bottle marked “tetracyte” to Patient 1’s wound. During an interview with LVN 1 on May 20, 2025, at 12:08 PM, LVN 1 stated she did not have Patient 1’s wound care physician’s orders to review but followed the information sheet left at Patient 1’s house by a contracted wound care company. A review of a contracted wound care company’s information sheet titled “[name of contracted wound care company] Plan of Care,” undated, indicated a picture of a bottle of tetracyte drops and “Step 2, If applicable: Apply Tetracyte.” A review of Patient 1’s physician’s order, dated March 20, 2025, indicated, “tetracyte spray apply to affected site with every dressing change.” During an interview on May 22, 2025, 10:17 AM, with the Director of Patient Care Servies Designee (DPCSD), the DPCSD stated she had written Patient 1’s tetracyte verbal order and made a mistake. The DPCSD stated the order should have indicated tetracyte drops, not tetracyte spray and because of this error Patient 1’s MP was inaccurate. 2. A review of Patient 3’s care plan, undated, indicated, a start of care date of April 9, 2024, with a recertification period of April 4, 2025, to June 2, 2025. Patient 6 had diagnoses that included open wound to left lower leg, hyperlipidemia (abnormally high level of fats in your blood), and benign prostatic hyperplasia (BPH-A non-cancerous condition where the prostate gland is larger than normal). During a home visit observation on May 21, 2025, at 1:30 PM, with the Administrator/Director of Patient Care Services (Admin/DPCS) and in the presence of Patient 3’s family member, an observation of Patient 3’s actual medication bottles available in the home were compared with Patient 3’s most current MP showed: a. A bottle indicated a fill date of April 7, 2025, for tamsulosin, 0 (zero).4 (four) mg (milligrams-a unit of measurement), take one capsule by mouth at bedtime. The MP indicated tamsulosin, 0.4 mg, take two capsules by mouth at bedtime. b. A bottled indicated ibuprofen 100 mg in 5 (five) ml (milliliters-a unit of measurement). The MP indicated ibuprofen 100mg, give 5ml by mouth every six-eight hour, as needed for pain. c. A bottle indicated a fill date of April 7, 2025, for atorvastatin 20 mg, take one tablet by mouth once a day and the atorvastatin was not listed on the MP. During a follow-up interview on May 21, 2025, at 12:30 PM, with the Admin/DPCS, the Admin/DPCS acknowledged that atorvastatin was not indicated on the MP. The Admin/DPCS stated the tamsulosin should have been updated with the new physician’s order. The Admin/DPCS stated that medications should be checked at every nurse visit and nurses should have caught this and changed the medication orders. Patient 3’s family member stated that atorvastatin and tamsulosin were changed during Patient 3’s Primary Care Physician (PCP) visit. During an interview on May 21, 2025, at 1:49 PM, with the Admin/DPCS and Patient 3’s family member, Patient 3’s family member stated she gave 15 ml (1500 mg) of ibuprofen and not 5 ml (500 mg) of ibuprofen. A review of the agency’s policies and procedure titled, “Medication Profile,” undated, indicated, “…Purpose: To define the use of the medication profile in evaluating a patient's medication regimen…. Procedure…3. A drug regimen review will be performed at the time of admission, when updates to the comprehensive assessments are performed, …4. During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen. This includes, but will not be limited to: A. Using the medication profile, in conjunction with other pertinent data, to evaluate the use of the drugs in the home setting. B. Using the medication profile to teach the purpose of medication, dosages, routes, administration times, side effects, and contraindications. C. Using the medication profile as a communication tool for other clinicians involved in care…”

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure a Registered Nurse (RN) provided a correct written patient care instruction to a Certified Home Health Aide (CHHA) for one of seven sampled patients (Patient 2) when the CHHA’s care plan (a written plan that outlines the specific services and care an individual needs to receive at home) indicated false assessments and incorrectly checked duty items for CHHA 1 to complete during Patient 2’s home visit. This failure resulted in Patient 2 receiving inappropriate care which could negatively impact Patient 2’s quality of life. Findings: A review of Patient 2’s face sheet (a document that gives a summary of patient’s information), indicated a start of care date of July 16, 2024, with a recertification period of July 16, 2024, to September 13, 2024. Patient 2 had diagnoses that included Alzheimer’s disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks). During a home visit observation on May 20, 2025, at 1:35 PM, with CHHA 1 and Patient 2’s family member, Patient 2 was observed in her room, lying down, awake, confused but aware of herself. CHHA 1 walked up to Patient 2 and extended her hands to guide Patient 2 to the shower. Once Patient 2 finished her shower, CHHA 1 guided Patient 2 out with her extended hands and led Patient 2 to sit down in Patient 2’s dining room chair. During an interview on May 20, 2025, at 2:15 PM, with CHHA 1 and Patient 2’s family member, CHHA 1 confirmed she did not review Patient 2’s plans of care prior to providing Patient 2’s home visit care. CHHA 1 stated she swabbed Patient 2’s mouth because Patient 2 did not like her teeth brushed. CHHA 1 and Patient 2’s family member confirmed Patient 2 did not have dentures. CHHA 1 stated that Patient 2’s family member washes Patient 2’s clothes. CHHA 1 also confirmed that she does not do any light housekeeping. CHHA 1 further stated that she performed range of motion (movement of joint) during Patient 2’s shower by instructing Patient 2 to raise her arm. During a concurrent interview and record review on May 20, 2025, at 2:25 PM, with CHHA 1, Patient 2’s CHHA plans of care, dated May 7, 2025, was reviewed. The CHHA plan of care indicated, clean dentures every visit, light housekeeping, wash clothes every visit, assist with ambulation (walking) with walker every visit, and active range of motion (AROM—when a patient uses the muscles to perform movement at a specific joint) to right and left arm and leg. CHHA 1 verified and confirmed Patient 2’s plan of care. During a concurrent interview and record review on May 21, 2025, at 2:04 PM, with the Administrator/Director of Patient Care Services (Admin/DPCS), Patient 2’s CHHA plan of care, dated May 7, 2025, was reviewed. The CHHA plan of care indicated, clean dentures every visit, light housekeeping, wash clothes every visit, assist with ambulation with walker every visit, and active range of motion to right and left arm and leg. The Admin/DPCS stated that she was also responsible as Patient 2’s RN staff. The Admin/DPCS verified and stated that denture care and washing clothes should not have been on the CHHA care plan. The Admin/DPCS explained her expectation for light housekeeping for CHHA 1 included clean up after Patient 2’s shower and fix the bed. The Admin/DPCS stated, CHHA 1 should have informed her to remove assisting Patient 2 with walker every visit since Patient 2 did not use a walker. The Admin/DPCS confirmed that Patient 2’s CHHA plan of care did not reflect Patient 2’s current assessment and contained inaccurate duty items for CHHA 1 to provide for Patient 2 during home visit. A review of the agency’s policy and procedure titled, “HOME HEALTH AIDE PLAN OF CARE,” undated, indicated, “…POLICY: Each patient receiving home health aide services will have an individualized plan developed and utilized to direct care performed by the assigned aide…. 2. The home health aide plan of care will be individualized to the specific patient and will include at least: A. Type of services/procedures to be provided, such as hands on personal care, the performance of simple procedures as an extension of therapy or nursing services, assistance in ambulation or exercises, and assistance in administering medications ordinarily self administered… D. Functional Limitations… H. Specific procedure(s) to be performed, including amount, frequency, and duration. I. Safety measures, including use of specific equipment. K. Reporting changes in patient's condition and needs… 4. The home health aide plan of care will be revised at least every 60 days, based upon a professional reassessment of the patient and at any time the patient's change of condition warrants revision…”

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure a Certified Home Health Aide (CHHA) provided all the services listed on the "Home Health Aide Care Plan [a written plan that outlines the specific services and care an individual needs to receive at home]," for one of seven sampled patients (Patient 2). This failure had the potential for Patient 2 not to receive the necessary services increasing the risk that the patient’s needs will not be met. Findings: A review of Patient 2’s face sheet (a document that gives a summary of patient’s information), indicated a start of care date of July 16, 2024, with a recertification period of July 16, 2024, to September 13, 2024. Patient 2 had diagnoses that included Alzheimer’s disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks). During a home visit observation on May 20, 2025, at 1:35 PM, with CHHA 1 and Patient 2’s family member, Patient 2 was observed in her room, lying down, awake, confused but aware of herself. CHHA 1 walked up to Patient 2 and extended her hands to guide Patient 2 to the shower. Once Patient 2 finished her shower, CHHA 1 guided Patient 2 out with her extended hands and led Patient 2 to sit down in Patient 2’s dining room chair. During an interview on May 20, 2025, at 2:15 PM, with CHHA 1 and Patient 2’s family member, CHHA 1 confirmed she did not review Patient 2’s plans of care prior to providing Patient 2’s home visit care. CHHA 1 stated she swabbed Patient 2’s mouth because Patient 2 did not like her teeth brushed. CHHA 1 and Patient 2’s family member confirmed Patient 2 did not have dentures. CHHA 1 stated that Patient 2’s family member washes Patient 2’s clothes. CHHA 1 also confirmed that she does not do any light housekeeping. CHHA 1 further stated that she performed range of motion (movement of joint) during Patient 2’s shower by instructing Patient 2 to raise her arm. During a concurrent interview and record review on May 20, 2025, at 2:25 PM, with CHHA 1, Patient 2’s CHHA plans of care, dated May 7, 2025, was reviewed. The CHHA plan of care indicated, clean dentures every visit, light housekeeping, wash clothes every visit, assist with ambulation (walking) with walker every visit, and active range of motion (AROM—when a patient uses the muscles to perform movement at a specific joint) to right and left arm and leg. CHHA 1 verified Patient 2’s plan of care and confirmed that she did not follow Patient 2’s CHHA plan of care. During a concurrent interview and record review on May 21, 2025, at 2:04 PM, with the Administrator/Director of Patient Care Services (Admin/DPCS), Patient 2’s CHHA plan of care, dated May 7, 2025, was reviewed. The CHHA plan of care indicated, clean dentures every visit, light housekeeping, wash clothes every visit, assist with ambulation with walker every visit, and active range of motion to right and left arm and leg. The Admin/DPCS stated that she was also responsible as Patient 2’s RN staff. The Admin/DPCS explained her expectation for light housekeeping for CHHA 1 included clean up after Patient 2’s shower and fix the bed. The ADMIN/DPCS further stated her expectation for CHHA 1 is to check the CHHA plan of care prior to providing care and if there are any changes with the CHHA plan of care, then CHHA 1 should inform the ADMIN/DPCS. A review of the agency’s policy and procedure titled, “HOME HEALTH AIDE PLAN OF CARE,” undated, indicated, “…POLICY: Each patient receiving home health aide services will have an individualized plan developed and utilized to direct care performed by the assigned aide….2. The home health aide plan of care will be individualized to the specific patient and will include at least: A. Type of services/procedures to be provided, such as hands on personal care, the performance of simple procedures as an extension of therapy or nursing services, assistance in ambulation or exercises, and assistance in administering medications ordinarily self administered… D. Functional Limitations… H. Specific procedure(s) to be performed, including amount, frequency, and duration. I. Safety measures, including use of specific equipment. K. Reporting changes in patient's condition and needs… 4. The home health aide plan of care will be revised at least every 60 days, based upon a professional reassessment of the patient and at any time the patient's change of condition warrants revision…”

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the attending physicians were informed of patients’ discharged from the agency for two of seven sampled patients (Patients 6 and 7) when the discharge summary (a written document that details a patient's medical condition upon leaving a healthcare facility, summarizing their admission details, diagnosis, treatment received, current medications, and any necessary follow-up care) was not sent to the primary care practitioner (PCP) within five business days of the patients’ discharge. This failure had the potential to result in patients’ PCP being unaware of patients’ current health condition which could cause delayed in diagnoses or provided incorrect treatment decisions that may negatively affect patients’ health and safety. Findings: 1. A review of Patient 6’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of July 13, 2021, with a certification period of July 13, 2021, to September 10, 2021. Patient 6 had diagnoses that included Parkinson’s disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). A review of Patient 6’s physician’s order, dated February 3, 2025, indicated Patient 6 had expired in the hospital and had been discharged from the agency. During a concurrent interview and record review on May 19, 2025, at 3:14 PM, with the Office Manager (OM), Patient 6’s discharge summary, dated February 3, 2025, was reviewed. The discharge summary was created. The OM verified and confirmed, there was no documented evidence to indicate that the discharge summary was sent to Patient 6’s PCP (105 days after discharged). During an interview on May 19, 2025, at 3:23 PM, with the Director of Patient Care Services Designee (DPCSD), the DPCSD stated Patient 6’s discharge summary had not been sent to the PCP. 2. A review of Patient 7’s face sheet, undated, indicated a start of care date of August 29, 2024, with a certification period of August 29, 2024, to October 27, 2024. Patient 7 had diagnoses that included open wound to left ankle. A review of Patient 7’s physician’s order, dated April 25, 2025, indicated, Patient 7 had been admitted into the hospital and was discharged from the agency. During a concurrent interview and record review on May 19, 2025, at 4:40 PM, with the OM, Patient 7’s discharge summary, dated April 2, 2025, was reviewed. The discharge summary was created. The OM verified and confirmed, there was no documented evidence to indicate the discharge summary was sent to Patient 7’s PCP (47 days after discharged). The OM stated, the policy for discharge process was not followed. A review of the agency’s policy and procedure titled, "TRANSFER, REFERRAL, AND DISCHARGE CRITERIA AND PROCESS,” undated, indicated, “…DOCUMENTATION: Relevant information includes at least: 1. Consistent information which will facilitate patient service coordination will be documented in the clinical record. When a patient is discharged, transferred or referred to another organization, relevant information includes at least: A. Reason for transfer or discharge. B. Physical and psychosocial status at time of transfer or discharge. C. Summary of the care/service provided and progress toward achieving goals. D. Instruction and/or referrals provided to the Patient. E. Existence of any advance directives, if applicable. F. The date of discharge. 2. Information will be documented on the Discharge summary form. 3. A copy will be forwarded to the attending physician within five days. 4. The discharge record is organized according to the agency policy regarding clinical record contents. Documentation is reviewed by the clinical supervisor and/or designee and completed within five days of the discharge at which time it is removed from the active files..."

The following reflects the findings of the California Department of Public Health during a recertification survey conducted May 2, 2022 through May 5, 2022 Representing the Department: Surveyors: 35183, 41794, 45013 Census: 37 Unduplicated Admissions: 49 Home Visits with record reviews: 3 Record Reviews without home visits: 4 Sample Size: 7 The condition of participation was met.

Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to develop a back-up communication plan with Federal, State, tribal, regional and local emergency management agencies in the event of communications (phone service, including cellular phone and Internet) failure during a disaster or emergency, in a universe of 37 patients. This failure had the potential to place the agency’s patients at risk when the agency did not implement a back-up communication plan with Federal, State, tribal, regional and local emergency management agencies in the event of communications failure. A review of the agency’s policy and procedure titled “Section IV: Emergency Preparedness Advanced Planning,” dated March 2019, indicated the following: “5. Emergency Communications: [name of the agency] will establish methods of communicating both internally and externally during a crisis or disaster situation. Traditional communication systems may not be available (failure) or may be overwhelmed (overload) during such a critical event. Examples of alternate communication methods are cellular phones (possible phones with outside area codes), satellite phones (both of which may not always be reliable), Internet (if computer systems are operable), two-way radios and CB or HAM radios. Mass notification systems are another option.” The agency’s policy and procedure titled “Section IV: Emergency Preparedness Advanced Planning,” dated March 2019, indicated a section where the agency was supposed to identify which communication method, they chose for the primary means of external communication and the alternate or supplemental method of external communication, in the event of a disaster. This section was blank. During an interview with the Administrator Designee (AD) on May 5, 2022, at 9:36 AM, the AD stated he was responsible for the agency’s Emergency Preparedness Program (EPP). The AD stated he had not indicated the primary, alternate or supplemental method of external communication in the policy and procedure for the agency’s EPP. The AD stated he had not reached out to the San Bernardino Emergency Management Office to find out what alternate communication method the office would use in the event of a disaster. The AD stated the agency would need to use the same form of communication so they could communicate with the emergency management office.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to provide training to contracted staff on the emergency preparedness policies and procedures and “Emergency Management Plan,” in a universe of 37 patients. This failure had the potential to place the agency’s patients at risk when contracted staff were not trained on what to do during an emergency or disaster. A review of the agency’s policy and procedure titled “Section IV: Emergency Preparedness Advanced Planning,” dated March 2019, indicated the following: “17. Agency-Specific Emergency Preparedness Training Program: The Agency will ensure that all staff are appropriately trained regarding their roles in the emergency preparedness program. … The Agency will do the following: Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement and volunteers, (if applicable) consistent with their expected roles. Provide emergency preparedness training at least annually. Maintain documentation of the training, [Staff] Demonstrates knowledge of emergency procedures.” During an interview with a Physical Therapist (PT 1) on May 4, 2022, at 3:30 PM, PT 1 stated he did not remember being in-serviced on the agency’s Emergency Preparedness Program. A review of PT 1’s personnel file was conducted. There was no documented evidence to show PT 1 had received training on the agency’s emergency preparedness program. A review of the agency’s in-service binder dated 2021 to 2022 was conducted. The binder contained an Emergency Preparedness Program in-service sign in sheet dated January 14, 2022. The sign-in sheet did not indicate signatures from any contracted staff. During an interview with the Administrator Designee (AD) on May 5, 2022, at 9:42 AM, the AD stated he was responsible for the agency’s Emergency Preparedness Program. The AD stated he had no documented evidence to show contracted staff had been in-serviced on the agency’s Emergency Preparedness Program.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to evaluate their Emergency Preparedness Plan, after activation for the COVID 19 (coronavirus disease-an infectious disease caused by the SARS-CoV-2 virus) pandemic, in a universe of 37 patients. This failure had the potential to cause problems within the Emergency Preparedness Plan to go unrecognized and unaddressed. A review of the agency’s emergency preparedness binder dated 2020 to 2022, indicated the agency had activated its Emergency Preparedness Plan in response to the COVID 19 pandemic. This activation was equivalent to a community-based testing of the agency’s Emergency Preparedness Plan. There was no documented evidence to show the agency had conducted an evaluation of their Emergency Preparedness Plan after its activation in 2020, 2021 or as of May 5, 2022. During an interview with the Administrator Designee (AD) on May 4, 2022, at 3:26 PM, the AD stated he was responsible for the Emergency Preparedness Program. The AD stated the agency had activated their Emergency Preparedness Plan in 2020 in response to the COVID 19 pandemic. The AD stated when the Emergency Preparedness Plan was activated, it was counted as testing the Plan. The AD stated the agency had not evaluated their Plan for deficient areas or to identify issues at this time. A review of the agency’s policy and procedure titled “Section IV: Emergency Preparedness Advanced Planning,” dated March 2019, indicated, “[name of agency] will consider the following points regarding exercises and drills: …Every exercise and drill will be properly documented to include those individuals who participated, issues identified, and corrective actions taken to correct deficient areas. The reports shall be maintained on file within the Agency for a period of five years.”

The following reflects the findings of the California Department of Public Health during a recertification survey conducted May 2, 2022 through May 5, 2022 Representing the Department: Surveyors: 35183, 41794, 45013 Census: 37 Unduplicated Admissions: 49 Home Visits with record reviews: 3 Record Reviews without home visits: 4 Sample Size: 7 All conditions of participation were met.

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to use quality indicator (a measurable element of the agency’s practice that can be used to assess the quality of care provided) data from OASIS (Outcome and Assessment Information Set) to monitor the quality of the agency’s services. In addition, the agency’s Governing Body (GB) failed to approve the frequency and detail of the Quality Assessment Performance Improvement (QAPI) program’s data collection, in a universe of 37 patients. This failure had the potential to cause problems in health outcomes, patient safety and quality of care, to go unrecognized and unaddressed. 1. A review of the agency’s QAPI Program Binder dated 2021 to 2022 indicated tracking of the following quality indicators: a. Patient infections b. Complaints c. Falls d. Hospitalizations e. Clinical record audits There was no documented evidence to show tracking of a quality indicator obtained from OASIS. During an interview with an Assistant QAPI Coordinator (A/QAPI/Coord) on May 4, 2022, at 9:35 AM, the A/QAPI/Coord stated a quality indicator had not been chosen from QASIS therefore no tracking had been done. The A/QAPI/Coord stated she was unaware of this requirement. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on May 4, 2022, at 11:38 AM, the Admin/DPCS stated she was responsible for the QAPI program. The Admin/DPCS stated a quality indicator had not been chosen from OASIS data because she had been unaware of this requirement. A review of the agency’s policy and procedure titled “Quality Assessment and Performance Improvement (QAPI) Plan and Program,” dated October 2018, indicated the following: “Program Scope … 3. The program must utilize quality indicator data, including measures derived from QASIS, where applicable, and other relevant data, in the design of its program. Use of OASIS Data 1. The Home Health Agency utilizes the following OASIS reports: Home Health Compare, Outcome-Bases Quality Monitoring (OBQM) Potentially Avoidable Events Report and Patient Listing, Outcome-Based Quality Improvement (OBQI) Outcome Report, Patient/Agency Characteristics Report, Submission Statistics by Agency Report, Error Summary Report by Home Health Agency. 2. Quality Assessment and Performance Improvement (QAPI) activities include obtaining and systematically analyzing OASIS reports to: collect and trend data to monitor performance, recognize statistically significant data, identify patient population trends, establish criteria for focused review, identify and reduce risk, investigate factors that contribute to potentially avoidable events, determine staff education that can promote improved outcomes, use evidence-based practices in quality assessment and performance improvement initiatives.” 2. A review of the agency's "Corporation Minute Book," undated, was conducted. There was no documented evidence to show the Governing Body (GB) approved the frequency and detail of the QAPI program’s data collection. There was no documented evidence to show a cumulative findings report had been sent to the GB by the QAPI Committee. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on May 4, 2022, at 11:38 AM, the Admin/DPCS stated she was a member of the Governing Body (GB) and the GB had not approved the frequency and detail of data collection for the QAPI program. A review of the agency’s policy and procedure titled “Quality Assessment and Performance Improvement (QAPI) Plan and Program,” dated October 2018, indicated, “The frequency and detail of the data collection must be approved by the Governing Body. The frequency of monitoring is monthly. A summary if data collection, analysis, recommendations for improvement and report of cumulative findings will be prepared by the QAPI Committee and forwarded to the Governing Body on a Quarterly Basis.”

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on interview and record review, the agency’s Governing Body (GB) failed to ensure its Quality Assessment and Performance Improvement (QAPI) Program was evaluated for effectiveness, in a universe of 37 patients. This failure had the potential to cause a QAPI program which did not address the complexity of the organization and its services and ineffective improvement actions. A review of the agency's "Corporation Minute Book," undated, was conducted. There was no documented evidence to show the Governing Body (GB) reviewed the agency’s QAPI program, addressed priorities for improved quality of care and patient safety or evaluated improvement actions for effectiveness. There was no documented evidence to show a cumulative findings report had been sent to the GB by the QAPI Committee. There was no documented evidence to show the Administrator/Director of Patient Care Services (Admin/DPCS) reported QAPI Committee findings to the GB on a quarterly basis. During an interview with the Admin/DPCS on May 4, 2022, at 11:45 AM, the Admin/DPCS stated she was a member of the GB. The Admin/DPCS stated she could not show the GB had reviewed the agency’s QAPI program, addressed priorities for improved quality of care and patient safety or evaluated improvement actions for effectiveness. The Admin/DPCS stated she could not show a cumulative findings report had been sent to the GB by the QAPI Committee or that she reported QAPI Committee findings to the GB on a quarterly basis. A review of the agency’s policy and procedure titled “Quality Assessment and Performance Improvement (QAPI) Plan and Program,” dated October 2018, indicated the following: “Responsibility/Accountability: 1. The Governing Body is ultimately responsible for an ongoing QAPI and patient safety program that is defined, implemented and maintained. The Governing Body must ensure that the program reflects: the complexity of its organization and services, involves all Agency services (including those services provided under contract or arrangement), focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions. The Governing Body takes actions that address [name of agency] performance across the spectrum of care, including the prevention and reduction of medical errors. Addresses priorities for improved quality of care and patient safety. Ensures that all improvement actions are evaluated for effectiveness. Addresses any findings of fraud or waste.”

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to develop a policy for staff to qualify for a temporary delay of a COVID‐19 vaccination and failed to develop actions the facility would take for staff that refused a COVID‐19 vaccination and did not qualify for an exemption, in a universe of 37 patients. This failure had the potential to cause staff to receive a COVID-19 vaccination before it was safe and the agency to experience a staff shortage. A review of the agency’s policy and procedure titled “COVID-19 Mandatory Vaccination Policy,” dated February 22, 2022, was conducted. There was no documented evidence to show a policy and procedure had been developed for staff to qualify for a temporary delay of a COVID‐19 vaccination or actions the facility would take for staff that refused a COVID‐19 vaccination and did not qualify for an exemption. During an interview with an Administrator Designee (AD) on May 5, 2022, at 9:17 AM, the AD stated he was responsible for the COVID-19 staff vaccination program. The AD stated he could not show the agency developed a policy and procedure for staff to qualify for a temporary delay of a COVID‐19 vaccination or what actions the facility would take for staff that refused a COVID‐19 vaccination and did not qualify for an exemption.